Download Patient name Dr.: _____ Sex: M F How would

Patient name
Mr.
Mrs.
Miss
Dr.: ____________________________________
Ms.
Last
Sex:
M
F
First
Age: ________
Middle
Hobby/Interest: ______________________________________________________
Home address: ___________________________________________
Street
Own
_____
How would you like us to address you? (Example: Bob, Mary, Mr. Smith, Mrs. Miller): ___________________________________
Date of birth: _____ /_____ /______
Do you:
_______________________________
Rent
Lease
_________________________________________
______
__________
City
State
Zip
How long have you resided at this address? ____________
Previous address (if less than 1 yr):____________________________________________________________________
Home telephone: (______) _________________
cell phone: (______) _______________
Whom should we contact in case of emergency? __________________________________
How long? ___________
email: ___________________________________
Emergency telephone: (______) ________________
Whom may we thank for referring you? _______________________________________________________________________________________
Your Social Security No.: ________-________-________
Occupation: __________________________________________________________
Employer: ____________________________________________________________________________
Employer address: ________________________________________
Street
How long employed? ___________
_________________________________________
______
__________
City
State
Zip
Business telephone: (______) ____________________________________
Spouse’s name: _________________________________________________________________
Spouse’s date of birth: _____ /_____ /______
Spouse’s occupation: ______________________________________________________________________________________________________
Spouse’s employer: _____________________________________________________________________
Spouse’s employer address: ____________________________________
Street
How long employed? ___________
_______________________________________
City
_____
State
_________
Zip
Please provide names and ages of children in your family:
Have we treated any of your relatives?
Yes
No
If Yes, what was their name(s): ______________________________________________
________________________________________________________________________________________________________________________
Who would be financially responsible for this account?: __________________________________________________________________________
Do you have any orthodontic insurance?
Yes
No
If Yes, what is the name of Insurance Co.(s): 1. ________________________________
2. ___________________________________________
Name of subscriber: ________________________________________________ Subscriber’s Social Security No.: ________-________-________
357 West Governor Road, Hershey, PA 17033 • www.skorchingsmiles.com • 717-533-7400
MEDICAL HISTORY
Do you have or have you had:
Hepatitis ............................................................
Diabetes.............................................................
Epilepsy.............................................................
Asthma/Breathing problems .............................
Hay fever/Allergies ...........................................
Heart condition..................................................
Bleeding problems ............................................
Hemophilia........................................................
Liver problems ..................................................
Kidney problems ...............................................
Sinus problems..................................................
Radiation treatment ...........................................
Cancer/Leukemia ..............................................
Birth defects ......................................................
Seizures .............................................................
Speech problems ...............................................
Swallowing problems........................................
Fainting .............................................................
Any physical handicap ......................................
Any mental handicap ........................................
Frequent headaches ...........................................
Tonsils/Adenoids removed................................
AIDS or HIV positive .......................................
Prosthetic joints.................................................
Back problems...................................................
Major surgery ....................................................
DENTAL HISTORY
Do you have or have you had:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Any comments on any of the above or on other health matters you
would like us to know:
Any past injury to the head or face ..........................................
Yes
No
Any past injury to teeth............................................................
Yes
No
Any previous orthodontic treatment ........................................
Yes
No
If Yes, by who: ______________________________ When: __________
Anyone in the family had orthodontic treatment .....................
Yes
No
If Yes, by who: ______________________________ When: __________
Any near relative ever had facial or jaw surgery .....................
Yes
No
Any near relative ever had a noticeable receding
or protruding lower jaw ......................................................
Yes
No
Tooth sensitivity.......................................................................
Yes
No
Bleeding gums .........................................................................
Yes
No
Any unfavorable reaction to post medical or dental care ........
Yes
No
Frequent mouth ulcers .............................................................
Yes
No
Any previous extractions of permanent teeth ..........................
Yes
No
Recent dental x-rays ................................................................
Yes
No
Did you ever suck your thumb or finger? ................................
Yes
No
Do you bite your fingernails or other object? ..........................
Yes
No
Do you grind or clench your teeth? .........................................
Yes
No
Do you frequently chew chewing gum? ..................................
Yes
No
Do you smoke or chew tobacco? .............................................
Yes
No
Family dentist: __________________________________________________
Date of last visit: _______/_______/_______
What are your dentist’s concerns regarding your teeth and jaws:
Are you taking any medications containing bisphosphonates (boniva,
fosamax) for osteoporosis or cancer treatments?...
Yes
No
Drug allergies:
What are your concerns & what do you hope or expect that we might do for you:
Medications you are currently taking:
Premedication required? ...................................
Yes
No
Family physician: ______________________________________
JAW JOINT (TMJ) PROBLEMS
Family physician phone: (________) _______________________
Do you have frequent pain in jaws or jaw joints?....................
Yes
No
Are you presently being treated by a physician? ..
No
Has a doctor ever told you that you may have a TMJ problem? ..
Yes
No
If Yes, what for? _____________________________________
Are the jaw (or chewing) muscles frequently sore? ................
Yes
No
Do you have a clicking, cracking, popping or
grating sound in your jaw joints?........................................
Yes
No
Have you ever been hospitalized? ....................
Yes
Yes
No
If Yes, what for? _____________________________________
I hereby certify the above information is correct. I understand that where appropriate credit reports may be obtained.
____________________________________________________________________________________________________________
Signature
_______ /_______ /_______
Date
357 West Governor Road, Hershey, PA 17033 • www.skorchingsmiles.com • 717-533-7400
We are really happy you will be visiting our office, and we promise to give
you the very best orthodontic care possible! We also would like you to ENJOY
the time you spend in our office. To help us get to know you a little better,
please complete the following…
Today’s Date: ______ / ______/ ______
The name (or nickname) I like to be called is: __________________________________________
My favorite activity to do in my spare time: ___________________________________________
My favorite song or music group is: _________________________________________________
The last movie I saw was: _________________________________________________________
The last book I read was: _________________________________________________________
Do you have children?
If yes, how many? ______
Yes
No
Names: _______________________________________________
Something SPECIAL about you would be:
My friends/relatives come to Korch Orthodontics. Their names are:
357 West Governor Road, Hershey, PA 17033 • www.skorchingsmiles.com • 717-533-7400